Relation between pre-existing quality management measures and prevention and containment of COVID-19 outbreaks in 159 nursing homes in Tuscany: a mixed methods study

Background Nursing homes were often the focus of COVID-19 outbreaks. Many factors are known to influence the ability of a nursing home to prevent and contain a COVID-19 outbreak. The role of an organisation’s quality management prior to the pandemic is not yet clear. In the Italian region of Tuscany nursing home performance indicators have been regularly collected since before the pandemic, providing the opportunity to better understand this relationship. Objectives To test if there is a difference in the results achieved by nursing homes in Tuscany on 13 quality management indicators, when grouped by severity of COVID-19 outbreaks; and to better understand how these indicators may be related to the ability to control COVID-19 outbreaks, from the perspective of nursing homes. Methods We used a mixed methods sequential explanatory design. Based on regional and national databases, 159 nursing homes in Tuscany were divided into four groups by outbreak severity. We tested the significance of the differences between the groups with respect to 13 quality management indicators. The potential relation of these indicators to COVID-19 outbreaks was discussed with 29 managers and other nursing homes’ staff through four group interviews. Results The quantitative analysis showed significant differences between the groups of nursing homes for 3 of the 13 indicators. From the perspective of nursing homes, the indicators might not be good at capturing important aspects of the ability to control COVID-19 outbreaks. For example, while staffing availability is seen as essential, the staff-to-bed ratio does not capture the turn-over of staff and temporary absences due to positive COVID-19 testing of staff. Conclusions Though currently collected indicators are key for overall performance monitoring and improvement, further refinement of the set of quality management indicators is needed to clarify the relationship with nursing homes’ ability to control COVID-19 outbreaks.

'I would ascribe it more on training, in the sense of the importance of training in and of itself.Bottom line, it is easy to write a protocol, but the difficulty is then to transmit it to the operators.' Working on outcome performance indicators encourages a proactive approach to risk management.
'That is, if the good results with respect to certain clinical indicators are the result of a proactive approach to risk management and therefore of a culture based on the analysis of ... Elements that can lead to the occurrence of an event and get used to working in that way by the whole working group, in that sense there can be a positive influence…' (P33) Good outcome performance indicators may imply more attention to infection prevention prior to Covid-19.
'…people who had already been trained and had in any case also had experience in managing other types of infections, isolations, who knew how to do a proper sanitation, both of the hands, even of the instruments, of the bed, of the patient living area, in fact this helped a lot.' (P26) Good outcome performance indicators may imply less need for visits to emergency departments and hospitals, hence reducing Covid-19 exposure risk.
'certainly the good management prior to Covid, of pressure injuries, of infections […] probably allowed, we also thought, to limit access to the hospital, the emergency room.' (P11)

Possible explanation for the absence of an observable relationship
Covid-19 was a new challenge for which work on outcome performance indicators did not prepare.
'I completely disagree because they are two completely different aspects.Two events, two independent capacities.' (P34)

Possible explanation for the existence of an observable relationship
Often quality officers translate national and regional Covid-19 related guidelines and requirements into facility level protocols and procedures.
'Ok, regulations, ordinances were coming in, there was also the whole part relating to what was indicated by the Region to follow, etc. in the confusion of daily management.Having a quality manager who at that time was absolutely available Quality officers might have a different perspective than general management or administrative staff when establishing new protocols and procedures.
'then maybe the managers, the director ... are a little more sensitive to the bureaucratic aspect, and the relational aspect with the guest, with the relative or even with the care workers is lost a bit.Instead, the quality coordination figure, but also the nurse coordinator and care workers .... Well, in my opinion they are essential.I couldn't do without them.'(P20)

Possible explanation for the absence of an observable relationship
If there is no quality officer, somebody else would perform the role of translating Covid-19 related guidelines and requirements.
'There are two of us, plus the president of the board of directors, taking care of all this part here.So there is a formal appointment, but in my opinion […] What I think works is working together.

' (P19)
There is no relation, because once a case is recognized, it is already too late for any intervention to have a meaningful effect.
'The problem, in my opinion, lies in the fact that when a massive infection starts, or rather when I begin to notice the first case, […] I have already had it in the facility for four days.This means that even in a community in a bubble I will have the peak that will tend to give the maximum number of cases, regardless of this factor of having or not having the quality manager.' (P25)

Possible explanation for the existence of an observable relationship
Helpful to the extent that contingency plans were required and prepared because of certification requirements 'We already have evacuation plans for fire, earthquake and other emergencies and we also do various evacuation tests during the year.Surely it is a training that can be useful from all points of view.' (P17)

Possible explanation for the absence of an observable relationship
The requirements of any certification system did not foresee Covid-19, so there were no related requirements 'Even though one had been certified, there were additional unrequired things one had to cope with...'(P112)

Possible explanation for the existence of an observable relationship
If an electronic health record is part of an administrative software, than the record indeed helps.
'…as far as the Covid management is concerned, however, the electronic health record has given, let's say ... It has absolutely reduced the waste of time by the staff in data management.So, all the BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) 'It would be nice to know how much data was lost in those who were not using it.'(P16)

BMJ Open
Correlation between size and availability of software.
'Perhaps it is more probable that those who have administrative software are a larger structure and therefore, in most cases have larger outbreaks' (P19)

Possible explanation for the absence of an observable relationship
A software does not help in Covid-19 related activities.
'We, who have the electronic medical record, it's not like...It is certainly more convenient than the paper and all, but in relation to COVID it seems to me that ... Surely it is a useful, comfortable, faster, more dynamic device.But that's all.' (P20)

Possible explanation for the existence of an observable relationship
Good relationships with management and within work teams likely means easier and quicker uptake of new procedures.
'In places with a workplace climate where the person works well, feels good, certainly everything is easier, goals are reached more easily, etc.' (P27)

Possible explanation for the absence of an observable relationship
Dedication of staff was essential, but this is not the same as satisfaction.
'…finding ourselves in the unusual and strange situation due to Covid, we had a beautiful demonstration [of dedication]' (P13) The pandemic created a sense of responsibility among staff independent of job satisfaction.
'I believe that not only the satisfaction of staff had influence, but another factor has also come into play, that is the professionalism, that cannot be taken away from care workers or nurses' (P37) The pandemic created a sense of unity in the face of adversity independent of job satisfaction.
'But, as far as the motivation is concerned, the group working climate, it almost seemed that Covid somehow favored this feeling of being on the same team.'(P27) High turnover of staff may indicate that 2019 data are not really relevant.
'The multifaceted, multi-standard and multistrange staff that we -and perhaps also other nursing homes-have is a little wandering and a little wavering.And those from the cooperatives, especially the temporary workers, come and go.' Healthcare workers per available bed

Possible explanation for the existence of an observable relationship
More personnel allows more extensive precautionary measures.
'We needed [the extensive personnel] for 'my son had a contact' at a time when no one was vaccinated' (P11) Once personnel is infected, you have many absences.
'The difficult thing at that moment was also the liberation, for lack of a better term, of the person who becomes Covid negative.Because at the time it was different from now, when the end of isolation comes immediately, […] then there were biblical time intervals before the worker could work again.' (P26) [nursing home personnel] underwent periodic screening with antigenic swabs every 15 days, from 19 October 2020, something like that.[…] at the [local health authority level, that provides external nurses] this did not exist.It was done on a voluntary basis.So we could get nurses who in reality were not subjected to any screening.'(P24) '